How bad things are in the wake of a disaster should never obscure how bad things were in the first place. It is all too easy for outsiders to look at devastation in a place like Puerto Rico after Hurricane Maria and attribute all of the suffering and loss to forces outside our control -- to make the storm itself the sole proprietor of misery when America itself and a century of exploitative rule over the island should bear the brunt of the blame.
During one of his many attempts to diffuse the blame for his administration's anemic response to the damage caused in Puerto Rico, President Donald Trump pointed out that the island's electric grid and general infrastructure had been a mess before Maria ever hit. However, instead of demonstrating what he saw as his lack of culpability in the matter, Trump's comments merely underscored the systemic rot that the U.S. has cultivated in Puerto Rico, utilizing the island for its own selfish needs while casting aside the Puerto Rican people as second-class citizens.
Hurricane Maria cannot be held responsible for the fact that Puerto Rico has an HIV death rate higher than any U.S. state or that Puerto Ricans receive a substantially lower quality of care than citizens in the 50 states. Similarly, Maria cannot be blamed for the island's block-granted and grossly underfunded Medicaid system that receives less funding per resident than any U.S. state and could run out of money before the year is out, kicking up to 900,000 people off of their insurance.
No, those systemic failures to provide health care to the people of Puerto Rico are not born out of any natural disaster, but a man-made one. For generations, U.S. policy makers have treated Puerto Rico as little more than a resource colony, denying the American citizens who live there of autonomy and many of the opportunities available to those on the mainland.
"There's a before and an after, but there's also so not a before and after," said Rafael Perez Torruella, executive director for Intercambios Puerto Rico, a community-based harm reduction group that runs a syringe exchange program in the northeastern portion of the island. "We must talk about the damage and fallout caused by Maria within the context of the colonialization of Puerto Rico."
The federal government's Hurricane Maria response in Puerto Rico was constructed through the framework of a colony/empire and not for a region that is part and parcel of a nation. From the roadblocks to incoming aid set up by Jones Act, which mandates that only American ships helmed by American crews ferry goods and passengers between American ports, to the $4.9 billion in aid loaned to Puerto Rico and the U.S. Virgin Islands, while Texas and Florida were given grants they don't have to repay, the disaster response was woefully inadequate.
As a result, HIV service providers in Puerto Rico have very little in the way of help from both the federal government and the territorial/local government on island, particularly for those who operate clinics in rural areas where barriers to care became all too literal.
"We have to go where the people are, because they can't come to us," says Tania Rodriguez, who serves as special projects coordinator for Migrant Health Center, a health care and HIV service provider based in the Western portion of the island.
All of Migrant Health Center's 10 locations are running and seeing patients (although at the time of this writing four remain operating on generator power), but due to the extensive damage caused by Maria to the island's roads and the scarcity of gasoline, Rodriguez and her team have been forced to create makeshift mobile clinics to provide care to Puerto Ricans living with HIV. Three days a week, they form small teams of doctors, nurses and social workers who drive into isolated communities to provide HIV medication and general health care, but also to help residents with basic needs that they are struggling to meet.
"Many of these people in these rural areas still don't have running water," Rodriguez said, noting residents have been forced to take "baths" using nothing more than wet wipes, but that even those are hard to get. Leptospirosis, a bacterial infection caused by contact with water contaminated with animal urine, has become a significant problem on the island and has been linked to several deaths since Hurricane Maria hit. While the Puerto Rico Department of Public Safety claims that the official death toll from Maria is 64 people, the New York Times has concluded that over 1,000 people have died as a result of the storm and its aftermath.
While the response to Maria from the federal government has been underwhelming at best, there are those in Congress who are working toward legislative solutions to provide people in Puerto Rico with the care they need. The most ambitious of these solutions is the Puerto Rico and Virgin Islands Equitable Rebuild Act of 2017. Sponsored by Sen. Bernie Sanders (I-VT) and co-sponsored by a host of Democratic leaders including Sens. Elizabeth Warren (D-MA) and Kirsten Gillibrand (D-NY), the bill proposes a $146 billion investment in recovery efforts that would reshape and revamp the island's entire infrastructure, including a total overhaul of its badly damaged energy grid.
Perhaps most important for people living with and affected by HIV, this legislation would lift the roughly $300 million cap on Medicaid funding for Puerto Rico and make sure Puerto Rico's Medicaid program is funded via the same formula used with all 50 states. If implemented, these two simple changes would see the percentage of federally funded Medicaid spending in Puerto Rico jump from about 15-20% to 83%.
Given the makeup of the current Congress, this legislation has virtually no chance of passage. Regardless of politics, we must stand in solidarity with our fellow Americans in Puerto Rico and demand that they receive equitable and just treatment from the government that supposedly represents them.
If you would like to donate to assist people living with or impacted by HIV in Puerto Rico, you can give to AIDS United's Hurricane Relief Fund.